A middle-aged parent goes to the emergency room for symptoms of dizziness, headache, and suicidal ideation

Question

The nurse assesses the patient for substance use, employment, child-rearing stressors, relationships with coworkers, recurring physical symptoms, and marital problems. The nurse is: 1. Failing to focus on the seriousness of the primary presenting problem.
2. Establishing rapport that will decrease the likelihood of suicide.
3. Doing more than the nurse's share of the interdisciplinary assessment.
4. Formulating a holistic–interactional assessment needed to interpret clinical data.

Answer 1

4
Rationale: The nurse must conduct a holistic assessment and synthesize factors from many aspects of an individual's life to determine an effective plan of care. The nurse functions as an autonomous member of the mental health team and assumes a broad range of responsibilities within the RN scope of practice. Belief that developing rapport will decrease suicidal ideation indicates a knowledge deficit regarding the phenomenon of depression/suicidal ideation, and an unrealistic perspective on the role of the nurse. Predetermining what the presenting problem is before making a thorough holistic assessment indicates that the nurse does not understand the complexity of the human condition.